Community of Communities Process Document 2017-2018
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Community of Communities
Process Document
2017-2018
Artwork: Fay Read, Christ Church Deal
Contents What is a Therapeutic Community? ................................................................................... 1 Community of Communities .............................................................................................. 1 The College Centre for Quality Improvement ...................................................................... 1 Who can join Community of Communities? ......................................................................... 2 Community of Communities Membership Types ................................................................ 2 Membership Fees ......................................................................................................... 2 The Standards ................................................................................................................ 5 The Core Standards and Core Values .............................................................................. 5 Self-Review ................................................................................................................. 7 Peer-Review ................................................................................................................ 7 Associate Membership Process .......................................................................................... 8 Developmental Membership Process ................................................................................ 10 Full Membership Process ................................................................................................ 12 Accreditation Membership Process ................................................................................... 16 Accreditation Decisions ............................................................................................... 21 Accreditation Appeals Procedure ................................................................................... 22 APPENDICES................................................................................................................. 26 APPENDIX 1: The Principles and Therapeutic Rationale of Therapeutic Communities ........... 26 APPENDIX 2: Core Values ............................................................................................ 27 APPENDIX 3: Quoracy Guidance ................................................................................... 28
What is a Therapeutic Community?
“A therapeutic community is a planned environment which exploits the therapeutic value of social
and group processes. It promotes equitable and democratic group-living in a varied, permissive
but safe environment. Interpersonal and emotional issues are openly discussed and members can
form intimate relationships. Mutual feedback helps members confront their problems and develop
an awareness of interpersonal actions.”
From The Principles and Therapeutic Rationale of Therapeutic Communities, Haigh and Worrall
2002 (See Appendix 1).
The Therapeutic Community (TC) model is a value-based approach and these values are
articulated in a set of 10 TC Core Values (see appendix 2). Evidence-based mental health care is
generally accepted as necessary, but it has been strongly argued that it is not sufficient without
reference to underlying values (Fulford, 2004; Cloninger, 2006). The Core values describe the
journey of processes an individual experiences in order to develop good mental health by
explaining the journey undertaken by a member of a therapeutic community, beginning with
attachment and progressing to responsibility. The briefing paper for the development of the Core
Values can be found on the Community of Communities website here:
http://www.rcpsych.ac.uk/PDF/CSCV%20Final%20Briefing%20Paper.pdf
Community of Communities
The Community of Communities (CofC) is a standards-based quality improvement and
accreditation network working with Therapeutic Communities (TCs) in the UK and abroad. The
project works in partnership with The Consortium for Therapeutic Communities (TCTC) and the
Planned Environment Therapy Trust (PETT). Funding is from members’ subscriptions.
Member communities are located in Health, Education, Social Care and Prison settings. They cater
for adults and children with a range of complex needs, including:
Personality Disorders
Attachment Disorders
Mental Health Problems
Offending Behaviour
Addictions
Learning Disability
CofC was set up in 2002 in conjunction with the Association of Therapeutic Communities (ATC)
and the Royal College of Psychiatrists with the aid of a Big Lottery grant. Specialist networks for
children’s, addiction and learning disability services were developed in 2004 with an additional
Big Lottery Grant in association with The Charterhouse Group of Therapeutic Communities, the
European Federation of Therapeutic Communities, and the Camphill Village Trust, respectively.
We are based at the College Centre for Quality Improvement.
The College Centre for Quality Improvement
The College Centre for Quality Improvement (CCQI) is a department within the Royal College of
Psychiatrists. The centre runs over 20 quality and accreditation networks for specific mental
health services, and works with over 90% of the mental health services in the country.
1Who can join Community of Communities?
The Community of Communities encourage any service which embraces the Core Values and TC
approach to consider membership to help develop their practice against the Service Standards.
Whilst we welcome and do work with organisations, the focus of the review process will be with
individual communities. Organisations need to clearly identify which service is part of CofC and
should discuss membership with the project team.
Community of Communities Membership Types
Membership at all levels demonstrates a commitment to a network of quality improvement and
provides access to a wider community of support which promotes and encourages shared
learning.
Associate Membership – available for international members who are unable to commit to
the requirements of full membership. This membership provides an annual assessment of the
self-review of the Core Standards and portfolio evidence.
Developmental membership – available for one cycle only. This membership provides a
self-review of the Core Standards and access to CofC training, workshops and attendance at
peer-reviews.
Full membership – provides a full peer-review against the standards, and full participation
in an ongoing process of quality improvement including access to CofC training and
workshops.
Accreditation membership – available to communities after two full membership years and
on demonstrating the community fulfils required criteria. Accreditation membership provides
an award which demonstrates the community meets critical Therapeutic Community
standards.
Membership Fees
Full details of membership fees can be found on our website:
www.communityofcommunities.org.uk
Invoicing
Members will be invoiced at their current level of membership in the first week of April in iterative
cycles unless CofC is requested not to do so, or receives notification that a service wishes to
upgrade their membership.
2Membership differences
Developmental
(International
Accreditation
membership
membership
membership
membership
Associate
only)
Full
An action planning template x x x x
Support and guidance from the CofC team x x x x
Certificate of participation x x x x
A local report summarising areas of achievement
x x x x
and areas for improvement
Access to discussion forum x x x x
Access to CofC training and workshops x x x x
Participation in peer-reviews of other members x x x x
A self-review workbook (all standards) x x x x
A review visit from a peer-review team to validate
x x
self-review and share learning
Use of membership logo for commitment to quality
x x
improvement
Input from a TC specialist x
Submission of local report to the therapeutic
x
community accreditation panel
Use of accreditation logo to demonstrate quality x
3What can all members expect from CofC?
Membership of a network of supportive relationships and TC knowledge
Opportunity to demonstrate the quality of therapeutic practice using agreed Service
Standards
A set of Service Standards for Therapeutic Communities
Opportunity to participate in reviewing and revising the Service Standards
An individual report on quality improvement
A National Report
An email discussion forum
Free workshops and training events
Discounted rate to annual forum
What is expected from members?
Provide a link person to liaise with the CofC team
Involve all community members in the CofC process as far as possible and the peer-
review process
Ensure community members are kept up-to-date with the CofC network and encourage
involvement
Train a minimum of one person a year as peer-reviewer and for them to attend a peer-
review
Provide a minimum of 1 trained peer-reviewer and 1 experienced community member
including client members, where appropriate, to attend peer-review/accreditation visits
and authorise accompanying travel costs
Provide a senior person with at least five years TC management experience to perform
the TC Specialist role on accreditation reviews of other members (accreditation
members only)
Supporting staff who are trained peer-reviewers to become a lead reviewer
Take responsibility for inviting key stakeholders from both internal and external
agencies (e.g. senior managers, referrers, statutory inspectors etc.) to attend the
communities’ peer-review/accreditation visit
Take responsibility for assisting CofC in disseminating important information to
members e.g. tell us about policy changes, relevant articles etc.
Commit to returning all necessary correspondence to the CofC team in a timely manner
Community of Communities Review Cycle
September
November
December
February
January
October
August
March
April
June
May
July
Membership confirmation
Peer-review date selection
Allocating peer-review teams
Self-review completion
Review period
Draft local reports
disseminated
Local reports finalised
4The Standards
The 9th Edition of Service Standards has been developed in conjunction with our members
and on best available evidence and expert consensus. The standards provide a tool to
assess a service as a Therapeutic Community. This process provides an opportunity for
quality improvement by identifying areas of achievement and areas for improvement
against the standards.
The Service Standards contain a total of 127 Elements, broken down into 30 Standards
and 97 supporting Criteria. Each Standard has typically three or four criterion statements,
which define what we would expect to see in a service that meets the overarching
standard. The criteria are not an exhaustive list, and communities are able to identify
additional ways they meet the standard during the self and peer-review process. It is
important to note that each criterion is accompanied by a number, 1, 2 or 3. These number
represent the “typing” of associated with the accreditation process. They are however,
relevant to the peer-review process in that they identify those criterion that are:
Type 1: Essential
Type 2: Expected in a good Therapeutic Community
Type 3: Recognised as best practice
To be deemed as meeting the overarching Standard, the TC must meet both Type 1 and
Type 2 criterion.
The Core Standards and Core Values
Therapeutic Community practice is underpinned by a set of Core Values and specific
theoretical and philosophical position regarding treatment and care. The Core Values allow
us to make sense of the Core Standards and their primary importance for TC practice and
approach. The Core Standards operationalise the Values and have been agreed by all
members to essentially define a Therapeutic Community with the other 20 standards and
sections identifying the necessary infrastructure and operational factors to support and
maintain the culture.
The Core Values
The Core Values, below, allow for a more in depth understanding of the meaning and
purpose of the Core Standards and it is important to hold them in mind when thinking
about your service and whether and how you meet the Core Standards.
Table 1:
Core Values
Healthy attachment is a developmental requirement for all human beings,
CV 1
and should be seen as a basic human right
A safe and supportive environment is required for an individual to develop,
CV 2
to grow, or to change
People need to feel respected and valued by others to be healthy. Everybody
CV 3
is unique and nobody should be defined or described by their problems alone
5All behaviour has meaning and represents communication which deserves
CV 4
understanding
Personal well-being arises from one’s ability to develop relationships which
CV 5
recognise mutual need
Understanding how you relate to others and how others relate to you leads
CV 6
to better intimate, family, social and working relationships
Ability to influence one’s environment and relationships is necessary for
CV 7 personal well-being. Being involved in decision-making is required for
shared participation, responsibility, and ownership
There is not always a right answer and it is often useful for individuals,
CV 8
groups and larger organisations to reflect rather than act immediately
Positive and negative experiences are necessary for healthy development of
CV 9
individuals, groups and the community
Each individual has responsibility to the group, and the group in turn has
CV 10
collective responsibility to all individuals in it
Table 2:
Core Standards
There is a clear Therapeutic Community model of practice that is
CS1
consistently applied across the service
Community Members are aware of the expectations of Community
CS2
Membership
Community Members are encouraged to form a relationship with the
CS3
Community and with each other as a significant part of Community life
Community Members work together to review, set and maintain Community
CS4
rules and boundaries
There is a structured timetable of activities that reflects the needs of
CS5
Community Members
All behaviour and emotional expression is open to discussion within the
CS6
Community
CS7 Community Members take part in the day to day running of the community
Everything that happens in the Community is treated as a learning
CS8
opportunity
Community Members share responsibility for the emotional and physical
CS9
safety of each other
CS10 Community Members are active in the personal development of each other
6Self-Review
The self-review element of membership is the foundation of the quality improvement
process. The self-review workbook contains the standards and criteria and requires the
community to consider the extent to which they meet each criterion. The community will
need to provide a score for each criterion and a comment as evidence. In addition, there
is also space for the community to demonstrate how they are meeting each overarching
Standard, based on the criteria.
As the basis for quality improvement, members are encouraged to think about the self-
review from the start of the cycle, ensuring as many views and opinions are included to
complete all sections. Communities are required to highlight specific areas of achievement
against the standards and also areas for development. Additionally, the community will be
asked to provide an update on any standards which were highlighted as areas for
improvement in the previous cycle.
Peer-Review
During the peer-review the peer-review team will review the criteria with the host
community, using the self-review comments to facilitate discussions. The peer review
team will also decide if each overarching Standard is met, or not met, through the scoring
of the criteria. To be deemed as meeting the overarching Standard, the TC must meet
both Type 1 and Type 2 criterion.
Peer-reviews incorporate elements of clinical audit and feedback that have been shown by
a Cochrane review to lead to improvements in practice (Jamtvedt et al 2007). This is a
critical part of the cycle, where valuable lessons are learned from sharing best practice
and from frank discussion about problems and exploring potential solutions. This process
brings further attention to the areas requiring development, and provides a space for
communities to start to think about what specific actions they would like to take, supported
by the ideas and experiences of the review team.
In the recent Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis,
2013) it was noted that:
“the creation of a caring culture would be greatly assisted if all those involved in the
provision of healthcare are prepared to learn lessons from others and to offer up their own
practices for peer-review” (p.76)
and recommended that:
“...peer-review therefore needs to be a key part of the delivery and monitoring of any
service or activity, and those involved need to demonstrate that this element of monitoring
and learning is integral to the process of compliance with fundamental standards and of
improvement.” (p.76)
7Associate Membership Process
8Benefits of Associate Membership
Associate membership provides international communities with an opportunity to
participate and be part of a quality improvement network, working with the Services
Standards to reflect on how the process can aid the service in quality improvement. Self-
reviewing against the standards provides an opportunity to evaluate the current service
provisions and develop core TC aspects.
Participation
Associate members are encouraged to complete a full self-review against the Service
Standards and identify areas of achievement and areas for development. The community
can use this to put together an action plan which supports the community to address the
areas for improvement. The community can submit self-review along with supporting
evidence to the CofC team.
The community will not host a peer-review visit but are able to provide members to take
part in visiting other communities as part of the peer-review process to learn and share
ideas. The Community of Communities is committed to supporting associate members to
access training and events and are working on ways to extend membership options.
Point to note
Associate membership is only available to services based overseas who are unable to
commit to the requirements of full membership.
9Developmental Membership Process
10About the Membership
Developmental membership is a “toe in the water” experience for those new to Therapeutic
Communities and/or the Community of Communities. It is only available for one year and
it is expected that developmental members will progress to full membership at the end of
their first year of membership.
Benefits of Developmental Membership
Developmental membership provides communities with an opportunity to participate and
be part of a quality improvement network, working with the Services Standards to reflect
on how the process can aid the service in quality improvement. Self-reviewing against the
standards provides an opportunity to evaluate the current service provisions and develop
core TC aspects.
Participation
Developmental members are encouraged to complete a full self-review against the Service
Standards and identify areas of achievement and areas for development. The community
can use this to put together an action plan which supports the community to address the
areas for improvement. This action plan should outline the steps the community plan to
take to address the areas for improvement. These will be drawn on in the subsequent year
to measure quality improvement against the standards. The community may also submit
an evidence portfolio to demonstrate meeting the standards.
The community will not be required to host a peer-review visit as a developmental member
but are encouraged to provide members to take part in visiting other communities as part
of the peer-review process to learn and share ideas.
Training and Development
Developmental members are able to take part in training workshops hosted by the
Community of Communities, free of charge.
11Full Membership Process
12Benefits of Full Membership
Full membership provides a full peer-review validation process to members, following the
submission of a complete self-review, and a focus on action planning and quality
improvement.
Full members are able to benefit from being involved in the peer-review process, which
includes visiting other services and hosting a review day. The review day will involve
members from other services visiting the community to help validate the self-review
comments and support the community in quality improvement through action planning
and shared learning.
Peer-review Standards
The peer-review process uses the Service Standards for Therapeutic Communities and
requires members to complete a full self-review of all Standards and their criteria. These
can be marked as to whether or not the community feel they are meeting the standards
and criteria, are partly meeting them, or not meeting them. Comments should be provided
for each criteria to allow for the score to be supported. Additionally, this commentary will
assist the peer review team who will be visiting a community to gain a good understanding
of the host community. Whilst doing this, it is encouraged that any areas of achievement
and any areas for development are highlighted as this will help the creation of an action
plan.
Application for full membership
Applications for membership can be made at any point during the review cycle which runs
from April 1st – March 31st. However, communities are encouraged to begin membership
at the start of the cycle, from April 1st to ensure they are able to make the most of the
additional benefits of full membership. Depending on the point of entry in the cycle,
Community of Communities will endeavour to provide a peer-review visit, although in
some circumstances this might not be possible and the community will have to undertake
their first peer-review in the subsequent cycle.
To apply for full membership please complete and return the membership form, which can
be downloaded from our website: www.communityofcommunities.org.uk, alternatively,
please contact a member of the project team (contact details are at the end of this
document).
13Peer-review Formats
Two types of review are available to members:
Focused standards review – This type of review is recommended for continuing
members and will support a focused action planning approach. This review encourages
members to select specific standards or areas of standards which they want to discuss
with the review team. These areas could reflect standards the community are performing
well on as well as standards the community are finding more difficult to meet.
Full standards review – This review involves discussion of standards from all sections
of the workbook. This style of review is recommended in the year preceding upgrading to
an accreditation membership, to allow the community to establish a detailed overview of
performance across all of the Therapeutic Community Service Standards.
Peer-review Methods
The peer-review day provides an opportunity for the host community to work alongside
an external peer-review team to validate the self-review scores and comments submitted.
The format the peer-review day takes is flexible and can include focussed discussions on
the standards, a review of evidence, observation (e.g. of a community meeting), action
planning and informal time. The host community is encouraged to work collaboratively
with CofC to organise a timetable for the day which enables as many members as possible
to participate. Additional sections of the day include a tour and lunch with the community.
14Review Team
All members of the review team are encouraged to support the community to identify
areas of achievement and areas for development. All members of the review team are
involved in compiling the report, using the information and evidence gathered throughout
the review day and self-review submission.
Lead reviewer
The lead reviewer is trained by the CCQI and will manage the review day, to ensure the
day remains focused and runs to time. This role includes supporting both the host
community and peer-review team in the evaluation of the standards. The lead reviewer
will also support the host community and peer-review team in the action planning elements
of the day. The lead reviewer is responsible for writing up the report from the review day.
Peer-review team
The peer-review team consists of 2-5 members from other communities. At least one of
the review team must come from a community in the same network as the host community
to ensure quoracy (see Appendix 3). The review team are required to take a lead in
engaging the host community in the discussions on the review day. They will be expected
to share knowledge and learning and help support the community to think about action
planning.
Local Report
The peer-review report includes the contextual information provided by the host
community, along with their service data and a section to highlight the improvements
made on the previous year’s action planning. This information will be transferred from the
self-review workbook.
The report will include the self-review scores and comments against all the criteria as well
as the peer-review team’s scores and comments against the standards covered on the
review day. The review team will also identify areas of achievement and the areas for
development which will be summarised in the report alongside an action planning template
which the community can use as an improvement tool for the following year.
There is space in the report which summarises the feedback from the host community
collected on the review day and an area for the peer-review team to summarise their
experience of the review day.
15Accreditation Membership Process
16The Accreditation Process
The Community of Communities has developed an accreditation process within the quality
improvement framework to recognise member organisations as Therapeutic Communities.
This process identifies and demonstrates good TC practice using the Service Standards in
an environment which engages in service evaluation and quality improvement.
Accreditation demonstrates that a community is fully meeting the essential standards
which underpin a Therapeutic Community.
Gaining recognition through an accreditation process provides:
Assurance to clients, commissioners, government departments, regulators and the
public that accredited TCs are of an acceptable quality and adhere to a clearly defined
TC model
Recognition for local achievements measured against rigorous national standards
A standardised base to support a continuous focus and development on improving the
quality of care they provide
Funders confidence to invest in accredited TCs
A professional identity for accredited TCs
Accreditation Standards
The accreditation process measures the community against criteria in the Therapeutic
Community Service Standards, 9th Edition. The criteria are categorised into three types:
Type 1 criteria are essential, Type 2 criteria are expected, and Type 3 criteria are desirable.
To achieve accreditation communities must meet all the Type 1 criteria, 80% of
Type 2 criteria and 30% Type 3 criteria.
Who can be an Accredited Member?
The Community of Communities provides accreditation across all member networks.
Application for Accreditation Membership
Accreditation membership has specific requirements and prerequisites. By signing up for
accreditation membership, the community agree to fulfil the requirements.
Accreditation membership prerequisites:
Completion of at least one year of full membership. Prior to accreditation it is also
recommended that the community completes a full peer-review of the standards
Demonstrate meeting the required national minimum standards for the service sector
Accreditation membership requirements:
Provide a link person to liaise with the CofC team
Involve all community members in the CofC process as far as possible and in the
accreditation process
Take responsibility for inviting key stakeholders from both internal and external
agencies (e.g. senior managers, referrers, statutory inspectors etc.) to attend the
communities’ accreditation visit
Provide a minimum of 1 trained peer-reviewer and 1 experienced community member
including client members, where appropriate, to attend peer-review/accreditation visits
and authorise accompanying travel costs
Provide a senior staff member, with at least five years TC management experience, to
carry out the TC Specialist role on accreditation reviews of other members and cover
the travel costs of sending a TC specialist to one review
17 Ensure community members are kept up-to-date with the CofC network and encourage
involvement in events and activities.
Assist CofC in disseminating important information to members e.g. tell us about policy
changes, relevant articles etc.
Commit to returning all necessary correspondence to the CofC team in a timely manner
Provide CofC with an update of their regulatory reports (Ofsted/CQC) each cycle
The accreditation visit covers all the Standards and their criteria, through discussion,
observation and documentary evidence.
The Therapeutic Community Accreditation Panel (TCAP) require communities to
demonstrate they are meeting national minimum standards set by national regulatory
bodies before an application for accreditation membership can be taken forward. Where
issues of concern have been made relating to national minimum standards, CofC must be
informed of these and provided with relevant action plans to demonstrate how
improvements are being made.
Services must identify how they are performing against national minimum standards, e.g.
Ofsted, CQC. To do this, members will need to inform CofC of their regulatory reports each
cycle, especially if there is a change in the outcome of these reports.
Communities who are reported as ‘Good’ or above, by either Ofsted or CQC are able to
participate in the accreditation programme. If a Children and Young People’s community
is identified as performing below these standards by Ofsted, their accreditation status
within the CCQI has the potential to be effected. If an adult democratic TC, or the trust in
which they sit, is identified as ‘requires improvement’, their accreditation status within the
CCQI has the potential to be effected. Each case will be discussed by the Accreditation
Panel on an individual basis.
All communities applying for accreditation membership must fully complete the
accreditation application form and supply all requested supporting documentation. CofC
are able to advise the community during the application process. Communities are
encouraged to reflect on the feedback from their previous peer-reviews before considering
applying for accreditation membership, and seek the support and advice of the CofC team
if needed.
18The Accreditation Cycle
Accreditation membership runs on a three year cycle:
Year 1: Accreditation review
Year 2: Self-review only
Year 3: Peer-review
Accreditation Review Format
The accreditation review is organised with the community. It is required for all community
members to be given an opportunity to attend and take part in the review day where
possible. The community is encouraged to take this into consideration when agreeing the
review date, e.g. all young people are available to participate, all staff are offered the
opportunity to take part. Due to the requirements of an accreditation review, the
community will not be able to continue their structured therapeutic programme during the
review day. The accreditation visit is the peer-review visit for the year and does not
constitute an extra visit.
Six weeks before the accreditation review, the community is required to submit their
completed self-review workbook and an evidence portfolio. The self-review workbook
should reflect the views of the whole community and will need to be submitted
electronically to the Community of Communities. The requested evidence portfolio can be
submitted either electronically or in hard copy. Evidence might include tracked group
notes, policy documents and individual case notes. For more details on the evidence
requirements please see The Accreditation Project Lead pack.
Documents submitted as evidence must be clearly labelled and they should identify which
standard the document evidences. Evidence within a document should be clearly tracked,
e.g. using different colours or notes to ensure the TC Specialist can clearly follow the
evidence trail.
If a community is unable to provide a self-review workbook and evidence portfolio by the
six week deadline they will need to inform CofC. Non-submission of completed documents
or un-satisfactorily completed documents may result in the accreditation review being
postponed or cancelled. In this instance, the community will be required to reimburse any
travel costs which the review team have incurred as part of the accreditation review visit.
The community should take responsibility for deciding how to organise the review day.
The aim of the day is for the review team to be able to validate the self-review. The review
day could include discussions, observation, a review of evidence or other creative ways to
demonstrate meeting the criteria.
Preparing the evidence portfolio is a substantial piece of work and the community is
advised to begin preparing the documents well in advance of their accreditation review.
Advice and support is available from CofC.
Accreditation Review Timetable
The community should put together a review timetable which will allow the review team
to see evidence for how the community meet the criteria. In order to accredit a community
some of the review team will need to meet with the staff only and with the service users
only and with the whole community all together. The review team will also need time to
meet at the beginning of the day and at the end of the day to write the report and to
review evidence. The timetable should be put together in consultation with CofC.
19Accreditation Review Team
All members of the accreditation review team are required to support the community to
identify areas of achievement and areas for development. All members of the review team
are involved in compiling the report from the accreditation review day. The accreditation
review team are not involved in the accreditation decision making process and are not
able to provide the community as to the expected outcome of the accreditation process.
TC Specialist
The TC Specialist takes a lead in the discussions the day and ensuring all data collected is
integrated into the report. The TC Specialist is an experienced staff member who meets
the specific requirements of the role and has undergone specific CofC training.
Peer-review team
The peer-review team includes between 3-6 staff members and/or service users from
other Therapeutic Community members of CofC (including the lead reviewer). At least one
members of the team must come from an accredited service and have 2 years of
experience in the community (see appendix 3). The review team are required to take part
in the whole day.
Lead Reviewer
The lead reviewer co-ordinates the review day and supports the review team to complete
all the required elements of the review. The lead reviewer will be a member from CofC
and will keep a record of the day.
20Accreditation Decision Making
The Therapeutic Community Accreditation Panel (TCAP) is a group of individuals
representing services from across the CofC member networks who meet as part of a
combined accreditation committee. TCAP make a formal recommendation about
accreditation based on the data collected during the self-review and accreditation visit.
Actions and recommendations of the Accreditation Panel will be subject to scrutiny by the
Combined Committee for Accreditation of which TCAP forms a part. This Committee has
an overall Chair who assures governance and consistency across those projects measuring
the quality of services which are managed by the College.
Successful accreditation will be dated from the date of the Combined Committee. For
communities who have gone through a deferral period, their accreditation will be
backdated to run from the date they were first presented to the Committee.
To maintain accreditation status, the community is required to uphold their accreditation
membership over the three year accreditation period, and demonstrate they are continuing
to meet the required service standards. If the accreditation standards are not being
satisfactorily maintained, the accreditation status of the community can be revoked by
TCAP. At the end of the three year accreditation period, the community will be required to
undertake an accreditation review. Accreditation status following a re-visit is subject to
alteration.
Accreditation Decisions
There are three categories of accreditation:
1) Accredited
Meet all Type 1 criteria
Meet 80% of Type 2 criteria
Meet 30% Type 3 criteria
2) Accreditation Deferred
o Fail to meet one or more Type 1 criteria but demonstrate the capacity to meet
these within a short time; and/or
o Fail to meet 80% or more of Type 2 criteria but demonstrate the capacity to
meet these within a short time; and/or
o Fail to meet 30% or more of Type 3 criteria but demonstrate the capacity to
meet these within a short time
The specific conditions aligned with the deferral will be outlined to the community; this
includes listing the criteria that need to be met and any additional requirements requested
by TCAP before accreditation is awarded. There may be a need for a further accreditation
visit within a specified time period to confirm that the community has met the criteria for
fully accredited status. If a revisit is required, the community will be responsible for paying
the expenses incurred by the visiting team. It is important to note that actions listed in
the report against unmet or partly met standards are a suggestion; the community could
take alternative action to meet a standard.
3) Accreditation Failed
o Fail to meet one or more Type 1 criteria with no evidence of the capacity to meet
these within a short time; and/or
o Fail to meet 80% or more of Type 2 criteria with no evidence of the capacity to
meet these within a short time
o Fail to meet 30% or more of Type 3 criteria with no evidence of the capacity to
meet these within a short time
21Accreditation decisions will be dated from the date the service is first presented to the
combined committee and will run for three years.
Where will the accreditation status be published?
Accredited members of CofC will be published on the Royal College of Psychiatrists website.
The online listing will include; the community name, the accredited status and the
accreditation period. Members that receive a failed or deferred accreditation status will not
be published.
Exceptions and the exercise of judgement
No exceptions can be made for how Type 1 standards are treated, however the
accreditation committee can use its discretion in relation to Type 2 and Type 3 standards.
Suspension/ withdrawal of accreditation
For a community to remain accredited over the 3 year accreditation period it must
demonstrate that it continues to meet the standards relating to the level of accreditation
awarded. If on interim peer-review a community fails to meet one or more Type 1, they
will be issued with a notice to improve. If after three months they cannot demonstrate
they meet the standard(s) in question, their accreditation status will be suspended for
three months. If there has been no improvement following this suspension period, the
accreditation status will be withdrawn. TCAP will be the body that recommends withdrawal
of accreditation.
Accreditation may be suspended temporarily if there are other grounds which suggest a
community no longer meet Level 1 standards or other concerns.
Accreditation Appeals Procedure
Appellant services that wish to make representations with regard to their accreditation
must initially submit them to the Head of the College Centre for Quality Improvement
within eight weeks of receipt of the accreditation decision by the Combined Committee
for Accreditation. Representations will then be dealt with according to this policy agreed
by the Combined Committee for Accreditation. Under no circumstances are such
representations to be made to reviewers or any other project staff.
Appeal definitions
“Accreditation level” A judgement made on the basis of a service’s
performance against the standards set and measured by
an accreditation programme. There are four levels of
accreditation; “excellent” (accredited as excellent will no
longer be offered from 1 January 2016); “accredited”;
“accreditation deferred”; “not accredited”. The
Combined Committee for Accreditation decides an
accreditation level for each service that it considers.
“Appeals Panel” A panel of three members of the Special Committee
for Professional Practice and Ethics, a sub-committee of
the College Council.
“Appellant service” A service undergoing the accreditation process that
appeals against an accreditation decision of the
Combined Committee for Accreditation.
22“Application” An appeal submitted for consideration under these
rules before acceptance.
“Council of the College” The senior committee of the College, chaired by the
President, whose remit includes the full management and
control of the work of the College in the area of quality.
“Deferral” Period of time within which a service not meeting
standards must show that it meets the
recommendations of the Combined Committee for
Accreditation.
“Combined Committee for The committee of the Royal College of Psychiatrists
Accreditation” with responsibility for all matters regarding
the accreditation of services.
“Head of the College The head administrator for the College Centre for
Centre for Quality Quality Improvement
Improvement”
“Review team” The multi-disciplinary team which carries out peer-
review visits to member services to ascertain whether
standards for accreditation have been met
1. Grounds for appeal
One or more of the following shall constitute grounds for an appeal under the appeal
procedure:
1.1 There is evidence of an administrative irregularity or procedural failure and
the service believes that, were it not for that irregularity or failure, the
accreditation decision would have been different.
1.2 The service believes it is meeting standards which the accreditation
committee has judged to be not met and which, if they were deemed to be
met, would affect the level of accreditation
2. Written appeals application
2.1 The Application must be submitted to the Head of the College Centre for
Quality Improvement in writing and include the following information:
2.1.1 the appellant service’s name, address and telephone number,
2.1.2 the grounds on which the appeal is made in accordance with
paragraph 1 above, and
2.1.3 appropriate supporting documentation such as evidence of compliance
with criteria (e.g. local policies, audits and protocols, information
leaflets) or details of an administrative error.
2.2 The Head of the College Centre for Quality Improvement may request in
writing within 28 days of receipt of the appeal further information from
the appellant service. The appellant service must supply such further
information within 28 days of the date on which the request for such
23further information was sent by the Head of the College Centre for Quality
Improvement. In the event of it not being supplied within the 28 day
period, the application will be automatically dismissed.
2.3 Providing that the application complies with the preceding provisions of
paragraphs 2.1 and 2.2, then not later than 28 days after receipt by the
Head of the College Centre for Quality Improvement of the application,
the Head of the College Centre for Quality Improvement will send to the
appellant service notice in writing that the application for the appeal has
been accepted and to whom it has been referred for consideration.
2.4 If, having submitted a formal appeal, an appellant service currently under
deferral fulfils recommendations of the accreditation committee and
resubmits itself to the accreditation committee with proof that a higher
level of accreditation is now merited, the attainment of the higher level
of accreditation will be deemed to supersede the appeal, which will then
automatically be treated as having been terminated.
3. Consideration of Appeals
2.5 Grounds for appeal under paragraph 1.1 only will be considered by the
chair of the Combined Committee for Accreditation in consultation with
the Head of College Centre for Quality Improvement who will review
the service’s peer review documentation and inform the appellant
service of any administrative or procedural error which as occurred,
and any consequent change to the appellant service’s accreditation
level.
2.6 A decision on an appeal under paragraph 1.1 would normally be
expected within 3 months of receipt.
2.7 If the appellant service is still dissatisfied following adjudication
provided under paragraph 3.1, a further appeal may be submitted
which will be considered by an appeals panel (see definitions).
2.8 Grounds for appeal under paragraph 1.2 will be considered by the
appeals panel. All supporting documentation submitted by the
appellant service, together with comments from the review team and
the minutes of the meeting of the Combined Committee for
Accreditation at which the service was originally discussed, will be
considered by the appeals panel.
2.9 The appeals panel will determine if it can reach a decision on the basis
of the documents presented to it. If this is not possible, the appeals
panel will reconvene at a later date to take evidence from relevant
parties, such as the appellant service, the review team, the project team,
and the chair of the Combined Committee for Accreditation.
2.10 The appeal can be determined in the following ways:
2.10.1 the original decision of the Combined Committee for Accreditation is
upheld, or
2.10.2 the accreditation level of the service is altered. This can be either up
or down, or
2.10.3 a revisit is required.
242.11 The appeals panel will present its determination in writing to the Head of
the College Centre for Quality Improvement who will send the
determination to the appellant service within 28 days of the date of the
appeals panel’s meeting. A report on the outcome of the appeal will be
presented to the Combined Committee for Accreditation.
2.12 Under normal circumstances, the appeals panel will not call on the bodies
that have representation on the Combined Committee for Accreditation.
2.13 The Royal College of Psychiatrists reserves the right to charge an
administrative fee in respect of a final appeal under section 3.3 to cover
the expenses of convening the appeals panel. The amount will be
determined from time to time by the Council of the College. If the
appellant’s appeal is successful the administrative fee will be refunded in
full.
September 2015
Date for revision: September 2017
25APPENDICES
APPENDIX 1: The Principles and Therapeutic Rationale of Therapeutic
Communities
Rex Haigh and Adrian Worrall 2002
TC principles and therapeutic rationale
Principles from all descriptions/ definitions Therapeutic value or rationale
1. Democratic, participative Allows healthy parts of the personality
to emerge and be used (e.g. self-
management and altruism)
2. Permissive, tolerant Allows difficult behaviour to occur.
Encourages catharsis, self-disclosure
and the assumption of individual and
collective responsibility.
3. Safe, boundaries Psychological containment can be
experienced and internalised.
4. Communicative, open and frank discussion Facilitates expression of distress and
understanding of its causes
5. Facilitate reality confrontation. The consequences of actions made
clear to individuals and the group.
6. Intimate, informal Allows trust to develop, and
encourages therapeutic playfulness.
7. Equitable, non-hierarchical Demonstrates that all members are
valued equally.
8. Varied environment Allows interaction in different settings,
and mutual examination of various
facets of the personality
9. Communalism, group living Helps client members explore all their
interactions and provide opportunities
for experimentation with new
behaviours in real situations.
Derived definition:
A therapeutic community is a planned environment which exploits the therapeutic value
of social and group processes. It promotes equitable (7) and democratic (1) group-living
(9) in a varied (8), permissive (2) but safe (3) environment. Interpersonal and emotional
issues are openly discussed (4) and members can form intimate relationships (6). Mutual
feedback helps members confront their problems and develop an awareness of
interpersonal actions (5).
Sources:
1. Rapoport, R. N. (1960) Community as Doctor. London: Tavistock.
2. Haigh, R. (1999) The quintessence of a therapeutic community. In Therapeutic
Communities: Past, Present and Future (eds P. Campling & R. Haigh), pp. 246–
257. London: Jessica Kingsley.
3. David Kennard, Janine Lees, (2001) A checklist of standards for democratic
therapeutic communities, The International Journal of Therapeutic Communities,
Vol. 22, No. 2.
26APPENDIX 2: Core Values
Core Values
Healthy attachment is a developmental requirement for all human beings,
CV 1
and should be seen as a basic human right
A safe and supportive environment is required for an individual to develop,
CV 2
to grow, or to change
People need to feel respected and valued by others to be healthy. Everybody
CV 3
is unique and nobody should be defined or described by their problems alone
All behaviour has meaning and represents communication which deserves
CV 4
understanding
Personal well-being arises from one’s ability to develop relationships which
CV 5
recognise mutual need
Understanding how you relate to others and how others relate to you leads
CV 6
to better intimate, family, social and working relationships
Ability to influence one’s environment and relationships is necessary for
CV 7 personal well-being. Being involved in decision-making is required for
shared participation, responsibility, and ownership
There is not always a right answer and it is often useful for individuals,
CV 8
groups and larger organisations to reflect rather than act immediately
Positive and negative experiences are necessary for healthy development of
CV 9
individuals, groups and the community
Each individual has responsibility to the group, and the group in turn has
CV 10
collective responsibility to all individuals in it
27APPENDIX 3: Quoracy Guidance
N.B. Review teams will consists of a minimum of 3 reviewers, and a maximum of 6
reviewers.
Peer Review Minimum Requirements
1 trained lead reviewer
1 trained peer reviewer
1 Person belonging to the sector of which the
Peer Review
review will take place.
And/or 1 Person with lived experience of living
or working in a TC for a minimum of two years
Accreditation Review Minimum Requirements
C of C lead reviewer
2 Children and Young People staff (1 of which
CYP Accreditation Review accredited)
1 trained peer reviewer
Trained TC specialist
C of C lead reviewer
2 staff / service users from NHS (1 of which
NHS Accreditation Review accredited)
1 trained peer reviewer
Trained TC specialist
HMP Review Minimum Requirements
Day one:
C of C lead reviewer
2 staff / service users from TCs
1 staff / service user HMP
HMP Audit Review Forensic Psychologist
TC Specialist
Operational auditor
Day two:
As day one but without PR team
While we encourage other services to send reviewers to different reviews, it has been
agreed that NHS PD Services can visit other Adult services ‘en masse’.
TC Specialist: A person in a managerial position in an accredited TC for a minimum of five
years.
28Community of Communities Team
Sarah Paget, Programme Manager
Sarah.Paget@rcpsych.ac.uk
0203 701 2675
Anna Cook, Deputy Programme Manager
Anna.Cook@rcpsych.ac.uk
0203 701 2674
Arun Das, Project Worker
Arun.Das@rcpsych.ac.uk
0203 701 2676
Katie Plummer, Project Worker
Katherine.Plummer@rcpsych.ac.uk
0203 701 2654
Royal College of Psychiatrists'
Centre for Quality Improvement
2nd Floor
21 Prescot Street
London
E1 8BB
www.communityofcommunities.org.uk
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